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Ayres et al (1) attempt to support the usefulness of the assessment of capacity in Borderline Personality Disorder by validating it as a diagnostic construct. This is a flawed approach for these reasons:
• People with a ‘diagnosis ‘can move in and out of states of competence as much as those of us without a diagnosis. What would the Mental Capacity Act (MCA) have to say about a suicidal newly bereaved mother (other than require us to invent a disorder of mind for her)?
• Acute presentations frequently preclude the ability to make a diagnosis. States of distress, psychoactive substances, lack of information etc. all cloud our ability to make clear assessments. Assessors vary in experience and competence, and judgements about diagnosis vary amongst even those with comparable experience and skill.
• Because the MCA and popular culture privileges the place of diagnosis in determinations of responsibility, this directs clinicians to first make a diagnosis and then, secondarily, to make a determination of capacity. This has the effect of predetermining capacity judgements based on diagnosis.
• Co-morbidity is a frequent finding in personality disorder. However the presence of ‘Axis I’ disorder has the effect of ‘trumping’ the Axis II in the minds of professionals, the public and, crucially, in patients themselves, colouring their own expectations of their ability to assume personal responsibility.
• Finally there is an issue of tautology. Capa...
• Finally there is an issue of tautology. Capacity could not be impaired without some impairment of our cognitive, perceptual or emotional state - the very abnormalities which describe disorder of mind. The absence of capacity is thus sufficient to denote a disorder of mind and the requirement to ‘name’ this directs clinicians to assign a diagnosis and attribute the incapacity to the diagnosis rather than the aspect of function which impairs their capacity.
It follows that we should be arguing to dissociate mental capacity from ‘disorder of mind’ and, instead, deepen our thinking, as their article attempts to do, about the application of capacity judgements in clinical situations.
Ayres K, Owen G.S, Moran P. Mental Capacity and Borderline Personality Disorder. BJPsych Bull 2017; 41:33-36
Vol 41 Issue 1
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